288 Step Challenge The Use of Pedometers & Dietary Advice on the

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					        Mental Health and Learning Disabilities Research and Practice, 2008, 5, 288-299




Step Challenge: The Use of Pedometers & Dietary Advice on the Activity
   and Fitness Level of a Group of Adults with a Learning Disability

                            Jessica Adams1 , Marian Emly2




1
    Leeds Primary Care Trust
2
    Leeds Partnership Foundation NHS Trust




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J Adams, M Emly




    Step Challenge: ‘The Use of Pedometers and Dietary
    Advice on the Activity and Fitness Level of a Group of
    Adults with a Learning Disability’

    Jessica Adams, Marian Emly

    Abstract

    Eight service-users who were regular gym attendees were identified to participate
    in this project. Baseline fitness assessments were completed and pedometers
    issued. Individualised dietary advice was offered and accepted by six
    participants. Data recording of number of daily steps of each participant was
    completed over eight-nine weeks with regular rewards handed out for
    achievement and effort. Fitness assessments were repeated at five and nine
    weeks.

    Results

    Average weight loss = 2.9 kg
    Average waist measurement loss = 1.9”
    Average baseline weekly number of steps = 14,606
    A 57% increase of steps from week 1 to week 8-9.

    Conclusions

    The audit has demonstrated the value of using a pedometer to increase activity
    levels outside the gym with this population. The positive changes seen in fitness
    assessment figures correlate with the use of the pedometer. The results of the
    combination of increase in physical activity with dietary advice are inconclusive.

    Recommendations

    •   Continued use of pedometers with a support network and reward system.

    •   A body fat percentage calculation as an additional baseline assessment
        figure.

    •   A longer audit for dietary changes to be fully implemented.

    Keywords: Pedometer, Learning Disability, Fitness, Obesity, Activity

    The Leeds Physiotherapy Service for People with Learning Disability set up a
    weekly physiotherapy-run gym fitness session at a local leisure centre in 2002.
    This self-referral provision attempted to address the problem of health
    inequalities and barriers to physical activity experienced by adults with a learning
    disability in Leeds. Each attendee was allowed a settling-in period to learn about
    the gym equipment, and how to use it safely. During this period each attendee
    completed a baseline fitness assessment. An individual fitness programme was
    devised for each participant and monitored by the Physiotherapist leading the
    sessions.

    A 6 month audit of the gym fitness programme conducted in 2006 showed the
    value of exercise and targeted nutritional advice for this population. Based on



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                                           Step Challenge: ‘The Use of Pedometers & Dietary Advice on
                                           The Activity & Fitness Level of a Group of Adults with a LD’’



these recommendations, it was decided to conduct a further audit in 2007 looking
at the use of pedometers and dietary advice on the level of activity and fitness in
a group of adults who regularly attended the fitness sessions at the local leisure
centre.

Background

The Healthcare Commission (2005) highlighted recent research conducted at the
University of Lancaster around healthcare inequalities and inconsistencies for
people with learning disability. People with a learning disability are at a higher
risk of obesity, eat less well and take less exercise than the general population.
The Disability Rights Commission (2006) published figures from a health survey
in Wales, identifying that 35% of people with learning disability are obese
compared with 22% of the general population.

The positive effects of exercise on cardio-respiratory fitness, levels of obesity and
mental health are well documented. Kyle et al (2004) found that physical activity
is able to limit weight gain and fat mass in both men and women. Melzer et al.
(2004) reported that regular activity has an impact on lowering blood pressure.

A systematic review by Penado and Dahn (2005) examined a prospective
observational study highlighting the effects of physical activity on systolic blood
pressure reducing the risks of diabetes-related complications and death with type
2 Diabetes, a common disease amongst learning disability individuals. It
additionally highlighted the evidence on physical activity preventing the
development of type 2 Diabetes. They also reported on the positive effects of
physical activity to improve mood and reduce symptoms of depression and
anxiety.

The Department of Health (2005) has recommended a physical activity plan
(‘Choosing Health: making healthy choices easier, 2005’) for everyone to
promote health.

However, people with learning disability experience barriers to physical activity,
including transport needs, staff support ratios, financial resources and unclear
policy guidelines for day and residential day services (Messent et al., 1998a,
1998b, 1999). These barriers impact negatively on general fitness and obesity
levels.

Context

In order to instigate change in cardio-respiratory fitness and obesity in people
with learning disabilities, it is first necessary to identify the physical activity levels
in their day-to-day life. The 2006 audit recommended the use of a pedometer; a
tool that measures the amount of steps you take, to achieve this end.

‘Walking the way to health’ (Walking the Way to Health (WHI) 2008) suggests the
use of a pedometer as a way to capture the daily number of steps completed,
hence the amount of physical activity undertaken by a participant. Walking,
particularly, is a more useful measure to capture activity in the learning disability
population compared to the general population due to the barriers learning
disabled adults face with other activities such as running and cycling.




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       Promoting walking as a simple way to increase physical activity is outlined in
       ‘Healthy Weight, Healthy lives: A Cross-Government strategy for England’
       (Cross-Government Obesity Unit, Department of Health and Department of
       Children, Schools and Families, 2008). The ‘Walking into Health’ campaign is
       aiming to get a third of England walking at least 1,000 more steps daily by 2012.

       The British Heart Foundation has further recommended 10,000 steps to increase
       fitness levels (BHF, 2007). Tudor-Locke and Bassett (2004) report that older
       people and those living with chronic conditions only take 3,500-5,500 a day. This
       was important to remember when identifying daily targets for the participants with
       learning disability.

       Using a pedometer to measure baseline activity has been evidenced by
       numerous studies. A systematic review published in 2007 ‘Using Pedometers to
       Increase Physical Activity and Improve Health’ (Bravata et al, 2007) suggested
       the use of a pedometer is associated with significant increases in physical activity
       and significant decreases in body mass index and blood pressure.

       Aims and Objectives

       The audit sought to assess and measure the following for a learning disability
       group:

       •   The value of using a pedometer to increase activity levels outside the gym.

       •   Any changes in fitness assessment figures as a result of the use of the
           pedometer and increases in activity levels.

       •   The value of specialist dietary advice alongside the use of the pedometer in
           improving fitness assessment figures.

       Method

       This was a small sample, within a time limited project which was used to assess
       the value of pedometer use and specialist dietary advice with adults with learning
       disability.

       In October 2007, eight service-users who were ambulant regular gym fitness
       attendees were identified to participate in this project.

       They were identified as the people:-

       •   Least likely to lose the pedometer.
       •   Most likely to co-operate (to want to take part).
       •   In need of changes to be made to activity levels/fitness assessment figures.

       One participant had hypothyroidism and was taking thyroxin which had not
       resulted in any weight loss prior to the start of the challenge. One participant had
       insulin-dependent diabetes and three other participants suffered with asthma.
       See Table 1 for participant profile.




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                                                      The Activity & Fitness Level of a Group of Adults with a LD’’



     Table 1 – Participant Profile
Part’ant    Sex      Age   Initial    Dietary Goal                           Support Network          Day
                           weight                                                                     service
                           (Kg)
1           Female   45    81         Current diet acceptable                Lives in group home      No
2           Female   36    86         Dietary advice not accepted            Lives with carer         Yes
3           Female   58    49         Dietary advice not accepted            Lives with sister        No
4           Male     57    115        Ensure portions of starchy carbs the   Lives alone              Yes
                                      same size each day
5           Female   43    80         Switch to semi-skimmed milk.           Lives with Mum and       Yes
                                      Swap sandwich at supper for fruit      Sister
6           Female   29    111.6      Current diet acceptable                Lives in group home      Yes
7           Female   37    98         Daily breakfast. Drink more fluids.    Lives alone              No
                                      Swap sugar drinks for diet versions.
8           Female   45    68         Current diet acceptable                Lives in group home      Yes


     Baseline fitness assessments were completed on all participants as part of the 1st
     Phase of preparation. The fitness measurements used were weight (Kg), BMI,
     Waist measurement (Inches), Blood pressure, resting respiratory rate and resting
     heart rate. This phase of preparation was completed in four weeks and also
     included:

     •     A reward system devised of certificates, keyrings, pens, flasks and medals to
           encourage compliance with the project.
     •     A contract signed by Home Carers and Day Service staff who agreed to
           support the service-user with the daily use of the pedometer and accurate
           daily recording of number of steps. This was done by completing home visits
           and/or day centre visits showing the equipment/rewards and paperwork.
     •     The provision of a T-shirt for all service users to show they were part of the
           challenge.
     •     All participants were asked at the home visit if they would like dietetic input as
           part of the project. Six participants agreed and were given a food diary to
           record their dietary intake in one week.

     The 2nd Phase involved the issue of the pedometers on their attendance to the
     gym over a two-week period. Pedometers were attached to the participant via an
     elastic band that fitted around their waist to ensure the pedometers did not fall
     off. Waist measurements of participants were taken at the initial home visit.

     The data recording of baseline number of steps of each service-user/participant
     was then completed over a two-week period where weekly targets were set.

     Completed food diaries were passed onto the Dietician who then visited each of
     the six participants at home to complete an assessment and set a dietary goal as
     appropriate. This was completed over a two-week period.

     During the initial three-week period, activity levels of each participant outside the
     gym fitness session were identified. Advice was issued as to where activity levels
     could be increased.

     Fitness assessments were completed again at five weeks and nine weeks. A
     celebratory gathering where prizes were distributed for successful increases in
     levels of activity took place after all results were gathered.




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J Adams, M Emly




      Concerns

      Our initial concerns for the success of the challenge were as follows:-

      •     Possibility of losing Pedometer
      •     Forgetting to put the Pedometer on each morning and to record the total at
            night and then remembering to reset it
      •     Ability to position the pedometer to record accurately the number of steps
            being taken
      •     Non-attendance at the gym to monitor the participant
      •     Christmas fell in the middle of the project therefore we anticipated decreased
            compliance/decreased physical activity and increased calorie intake.

      Results

      Of the eight participants, one was lost to non-attendance and one to other
      circumstances. Of the remaining six, the average weight loss was 2.9 kg. The
      average waist measurement loss was 1.9”. The average baseline weekly number
      of steps was 14,606. The average final week number of steps was 22,929.

      Table 2 - Fitness Assessment Results

          Participant Weight     Waist              Other fitness           Weekly average of
                      Loss       measurement        measurement             number of steps
                      (KG)       loss (inches)      improvement             at week 8-9

              1           5             3”          Blood pressure down           29,210
                                                       from 146/88 to
                                                           119/82

              2           6             0”          Resting HR down 13            31,212
                                                           BPM

              3           1             2”            Respiratory rate            37,172
                                                     down 2 breaths per
                                                          minute

              4           1            3½”                   Nil                  11,065

              5           1             2”                   Nil                  13,309

              6          2.6            1”                   Nil                  15,610


      Discussion

      There was a 57% increase in the number of steps from week one to week eight-
      nine. This could be attributed to the high level of participant compliance with the
      pedometer use, which the reward system may have directly contributed to.
      Additionally, over the eight-nine week period the accuracy of the recording
      seemed to improve.

      The two participants with the most weight loss completed a high weekly average
      of number of steps compared to other participants. However an active participant


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                                         Step Challenge: ‘The Use of Pedometers & Dietary Advice on
                                         The Activity & Fitness Level of a Group of Adults with a LD’’



with the highest weekly average number of steps lost the least weight recorded in
line with three other people who also lost 1kg. This individual in order to have
increased her weight loss may have benefited from an increased target for her
weekly steps. What is encouraging, however, is that everyone lost weight
regardless of the amount.

This audit used a small sample size. Participants had different levels of home
support to encourage and ensure accurate recording. Participants had different
levels of self-motivation.

The accuracy of the recording is questionable in two ways:

•   It is known that the pedometer is not 100% accurate
•   Human error may play a part in documenting the daily number of steps

However, it is likely that any errors in these measurements would be normally
distributed and therefore would not adversely affect the overall measure of trend.

The initial plan was to set a daily target but it was apparent after the first week
that a daily target was unrealistic as the levels of activity on each day varied
dramatically, especially when comparing the weekend to Monday to Friday.
Therefore a weekly target was set which was a more realistic goal.

With Christmas and New Year falling in the middle of the project there was a
significant drop in activity on the bank holidays. This will therefore have slightly
decreased the average number of steps compared to other weeks.

Two participants who attended the same Day Service were unable to include any
more activity in their weekly timetables. This was due to staffing and participant
reluctance to change their routines. This could have decreased their potential to
complete more steps and improve their fitness assessment figures. However,
their timetable already included three physical activity-based sessions a week
which could be argued is realistic in this participant group.

The level of similarity between each participant makes it difficult to establish the
ideal number of weekly steps required to achieve a positive outcome for this
group of people.

Receiving the rewards had a positive outcome on the participants’ compliance
with the challenge. Lifestyle changes occur when a person is either internally or
externally motivated. It is recommended that a person identifies an internal
motivator to be successful (Crogan, 2005). The reward system targeted the
internal motivator of the participants.

Conclusions

The audit has demonstrated the value of using a pedometer to increase activity
levels outside the gym. One prime example is participant 2 who lost the most
weight and instigated her own lifestyle change by walking instead of getting the
bus to three places she visits on a weekly basis. She was so pleased with her
success that she asked to continue to use the pedometer on her own. There was
a marked increase in the average number of steps taken in week one compared
to week eight-nine.




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       The audit has demonstrated changes in fitness assessment figures as a result of
       the use of the pedometer and increases in activity levels. The significant changes
       seen in fitness assessment figures correlate with the use of the pedometer.
       When analysing fitness assessments that were completed up to two-three years
       before the project started, it is clear that there were no significant changes in
       weight until the project started. However, different assessors using the
       standardised fitness assessment form could have introduced a degree of
       variability.

       The true value of specialist dietary advice alongside the use of the pedometer in
       improving fitness assessment figures is unclear. The participant with the most
       weight loss did not accept any dietary advice. However, she may have already
       made dietary changes or her carer did not believe her dietary intake needed
       changing.

       The two participants who lost the most inches off their waists (one of which also
       had significant weight loss) did accept dietary advice. Dietary changes often take
       time to implement and as this was only a short intervention the audit may not
       show a true picture of the influence dietary changes could have on fitness
       assessment figures.

       There was occasional inconsistency with daily recording on the charts which may
       have been because the participants had forgotten to put the pedometer on and/or
       record it/reset it. It was highlighted by a Day Service in the first week that
       participants were not wearing the pedometers appropriately and a visit was made
       to rectify this situation. One initial concern was proved wrong when none of the
       participants lost their pedometer.

       The support of home carers and Day Service staff enabled six participants to
       complete the project. The two participants who lived alone were the least
       successful in meeting their weekly step targets. In addition, the correlation
       between the two participants with the highest weekly average number of steps
       and the accurate recording of these with the fact they live with a specific carer
       and not in a group home signifies the importance of 1:1 support when completing
       a challenge like this.

       It is apparent that the rewards were a crucial part of the success of the challenge
       due to the accomplishment participants appeared/reported to feel when they
       received a certificate or other reward. The enthusiasm of participant 2 to continue
       this without any rewards is also a key point. This could illustrate that we have
       improved the understanding of the importance of physical activity in order to be
       healthy in some of our subjects.

       Recommendations

       1.         The use of pedometers with people with learning disability is a useful tool
                  to increase fitness levels and may be an aid to weight loss.

       2.         It is essential to have a strong support network for any individual with a
                  learning disability provided with a pedometer in order to maintain
                  compliance and motivation with the Step Challenge.

       3.         A reward system will maintain high levels of compliance and motivation
                  with the use of the pedometer.



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                                        Step Challenge: ‘The Use of Pedometers & Dietary Advice on
                                        The Activity & Fitness Level of a Group of Adults with a LD’’




4.   The use of the calculation of body fat percentage could be a valuable
     baseline assessment figure to use.

5.   A longer audit to allow dietary changes to be implemented and monitored
     would also be recommended.

6.   As a result of the findings of this audit, an obesity/lifestyle care pathway is
     being developed in Leeds for people with learning disabilities.




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      References

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      Crogan, E. 2005. ‘Assessing Motivation and Readiness to Alter Lifestyle
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                                            The Activity & Fitness Level of a Group of Adults with a LD’’



Messent, P. R., Cooke C.B. & Long, J. 1999. Primary and Secondary barriers to
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key=2032|0|2EC7485896907|p|748|0> Accessed 5 February 2008




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